Depth of Nursing Judgment
Baena de Morales Lopes et al. (2004) identified the major nursing diagnoses and interventions in a protocol used for victims of sexual violence in Sao Paulo, Brazil. The major nursing diagnoses identified were: rape-trauma syndrome, acute pain, fear/anxiety, risk for infection, impaired skin integrity, and altered comfort. Through the use of these nursing diagnoses, specific interventions were identified, such as administration of appropriate medications with explanations of expected side effects, emotional support, helping the client to a shower and clean clothes, and referrals to needed agencies. The authors used these diagnoses in providing care for 748 clients and concluded that use of the nursing diagnoses contributed to the establishment of bonds with their clients. These are just two examples illustrating how a standardized language has been used across nursing specialties and around the world.
Nurses need to express exactly what it is that they do for patients. Nurses need to express exactly what it is that they do for patients. Pearson (2003) has stated, “Nursing has a long tradition of over-reliance on handing down both information and knowledge by word-of-mouth” (p. 271). Because nurses use informal notes to verbally report to one another, rather than patient records and care plans, their work remains invisible. Pearson states that at the present time the preponderance of care documentation focuses on protection from litigation rather than patient care provided. He anticipates that use of computerized nursing documentation systems, located close to the patient, will lead to more patient-centered and consistent documentation. Increased sensitivity to the nursing care activities provided by these computerized documentation systems will help highlight the contribution of nurses to patient outcomes, making nursing more visible.
Nursing practice, in addition to the interventions, treatments, and procedures, includes the use of observation skills and experience to make nursing judgments about patient care. Because nurses use informal notes to verbally report to one another, rather than patient records and care plans, their work remains invisible. Interventions that should be undertaken to in support nursing judgments and that demonstrate the depth of nursing judgment are built into the standardized nursing languages.
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